Health inspection·February 22, 2024

F 0550 contractures of the right elbow, left elbow, right knee and left knee. Level of Harm - Minimal harm or potential for actual harm Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Residents Affected - Few Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, potential for discomfort, anticoagulant use with risk for side effects, potential for drug related complications, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Observation on 02/20/24 at 10:56 A.M. of Resident #5 found him lying in bed with his urinary catheter bag hanging on the side of his bed near the foot of the bed. The urinary catheter bag was 1/4 full of yellow urine and visible from the hallway. Interview on 02/20/24 at 11:00 A.M. with Resident #5's daughter revealed Resident #5 always had his catheter bag hanging on the side of the bed facing the door. Resident #5's daughter reported she had never seen it covered and commented it would be nice. Observation on 02/20/24 at 4:19 P.M. of Resident #5 found his catheter bag hanging on the side of his bed with yellow urine visible from the hallway. Interview on 02/20/24 at 4:23 P.M. with State Tested Nursing Assistant (STNA) #334 verified Resident #5's catheter bag was uncovered and visible from the hallway. STNA #334 reported Resident #5's catheter bag had always been that way and she was not aware there was a cover for it. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 2 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a significant change assessment in the Minimum Data Set (MDS) when a resident was started on hospice. This affected one resident (#17) of two residents reviewed for hospice services. The facility census was 58. Residents Affected - Few Findings include: Record review for Resident #17 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #17 included anemia, dementia, chronic obstructive pulmonary disease, heart disease, and anxiety. Review of the Minimum Data Set (MDS) comprehensive assessments revealed there was no significant change assessments in the resident's medical records. Review of Resident #17's care plans dated 11/20/23 revealed the resident had a focus for hospice services relating to chronic obstructive pulmonary disease and dementia. Interventions were appropriate for the focus. Interview on 02/22/24 at 1:55 P.M. Licensed Practical Nurse (LPN) #311 revealed he was the facility's MDS nurse and responsible for entering all MDS assessments into residents' medical records. LPN #311 verified after Resident #17 received an order on 11/20/23 to receive hospice services the MDS nurse had 14 days to complete a significant change assessment in the resident's medical records. LPN #311 verified he did not initiate or complete a significant change assessment in the medical records for Resident #17 after she started receiving hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 3 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure dependent residents received assistance with nail care. This affected one (#43) of one resident reviewed for nail care. The facility census was 58. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 07/02/22 with diagnoses of anxiety and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and was dependent on staff for showering, bathing, and personal hygiene. Review of the current care plan for Resident #43 revealed she had an activities of daily life (ADL) deficit and required assistance from staff for care. An intervention included checking nail length, trimming and cleaning on bath day and as necessary. Observation on 02/20/24 at 9:58 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation on 02/21/24 at 9:20 A.M. revealed Resident #43 lying in bed. The fingernails on her right hand were irregular lengths and appeared discolored and to have debris under them. Observation on 02/22/24 at 11:56 A.M. revealed State Tested Nurse Aide (STNA) #300 providing the noon meal to Resident #43 in her room. STNA #300 repositioned Resident #43 in bed to allow her to eat her meal more comfortably. STNA #300 offered assistance with eating to Resident #43 who stated she did not need any help with her meal. STNA #300 began to leave the room when the surveyor asked her to observe Resident #43's nails on her right hand. The nails on Resident #43's right hand were long and had darkness under them. Resident #43 stated it was chocolate. Upon inquiry, STNA #300 stated Resident #43 ate chocolate the day before. STNA #300 confirmed there was darkness under Resident #43's nails. Interview on 02/22/24 at 2:45 P.M. with the Director of Nursing (DON) confirmed Resident #43's care plan stated staff should provide nail care as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 4 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of facility policy, the facility failed to ensure ordered pressure ulcer reduction interventions were implemented as ordered. This affected one resident (#5) of three residents reviewed for pressure ulcer prevention. The facility census was 58. Residents Affected - Few Findings include: Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Reviewed of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Interventions for potential skin impairment included bilateral heel boots when in bed. Review of Resident #5's physician orders revealed an order dated 11/22/22 for heel boots when in bed every shift. Observation on 02/20/24 at 10:56 A.M. of Resident #5 found him lying on his back in bed with his heels on the bed. Resident #5's blue pressure relief boots were observed on the floor in front of his dresser. Interview on 02/20/24 at 11:00 A.M. with Resident #5's daughter verified Resident #5's was to be wearing his pressure relief boots when he was in bed and he did not have them on. Resident #5's daughter stated he normally had them on and she was not sure why he was not wearing them. Interview on 02/21/24 at 9:16 A.M. with Licenses Practical Nurse (LPN) #366 revealed Resident #5's pressure relief boots were taken off around 9:30 A.M. on 02/20/24. LPN #366 verified they had not been reapplied as they should have been. LPN #366 reported they should have been put back on after care was completed. Review of the facility policy titled, Skin Care Management, revised 11/17/22 revealed identified individual at risk for development of pressure ulcers and initiated management programs which stabilize or minimize underlying risk factors or change in condition. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 5 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of video recordings, staff interview, record review, and review of a personnel file, the facility failed to appropriately transfer a resident using a mechanical lift. This affected one (#46) of one resident reviewed for transfers. The facility census was 58. Findings include: Review of the medical record for Resident #46 revealed an admission date of 01/20/23 with diagnoses of dementia and contractures of both knees. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #46 was rarely/never understood and was dependent on staff for transfers. Review of the current care plan revealed Resident #46 required a mechanical lift with two staff for transfers. Further review revealed Resident #46 used an electronic video and/or audio monitoring device in her private room. Observation on 02/20/24 at approximately 10:40 A.M. revealed a sign inside Resident #46's door indicating voice and video recordings were in use. Review of video footage provided by the Ombudsman revealed a date-stamped video dated 02/13/24 at 1:07 P.M., lasting two minutes, and revealed Resident #46 being transferred from her wheelchair to the bed via mechanical lift. One staff, identified as State Tested Nurse Aide (STNA) #352, was observed performing the task. Additional observation of videos time stamped 02/13/24 at 1:23 P.M., 1:24 P.M., 1:26 P.M. and 1:27 P.M. revealed additional footage of STNA #352 transferring Resident #43 from the bed and attempting to transfer her to the wheelchair. Additional observation of the footage revealed Resident #43 hanging from the mechanical lift above her wheelchair and STNA #352 turning away from Resident #43 and appearing to leave the room at 1:27:16 P.M. Review of the subsequent video revealed STNA #352 returning to the room with the Director of Nursing (DON) at 1:27:57. Interview on 02/21/24 at 4:03 P.M. with the DON stated she was not aware of any family reporting concerns regarding transfers with a mechanical lift. Further, the DON stated she was not aware of any staff performing mechanical lifts alone (without a second person). The DON stated the expectation was for two staff to be present at all times when transferring a resident with a mechanical lift. The DON further stated she made herself available to assist with transfers and assisted recently with a mechanical lift transfer for Resident #43. The DON stated Resident #43 was ready to be transferred when she entered the room and did not respond to a question regarding whether Resident #43 was already suspended from the lift when she entered the room. Interview on 02/21/24 at 4:33 P.M. with Coach #370 confirmed she received videos regarding the mechanical lift transfer of Resident #43. Coach #370 stated she supervised all STNAs and identified STNA #352 was in the video with Resident #43. Further interview and observation of the video dated 02/13/24 at 1:07 P.M. to 1:09 P.M. with Coach #370 verified STNA #352 transferred Resident #43 using a mechanical lift with nobody else in the room. Coach #370 verified two staff should be used every time residents were transferred using a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 6 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm mechanical lift. Coach #370 stated she provided verbal education to STNA #352 via telephone explaining the requirement of two staff when transferring residents with a mechanical lift. Coach #370 stated she did not complete a disciplinary action against STNA #352, did not provide education to any additional staff after the incident, and did not do any audits on STNA #352 or other staff to ensure the appropriate process was followed when using a mechanical lift. Residents Affected - Few Follow-up interview with Coach #370 on 02/21/24 at approximately 5:40 P.M. revealed she shared the concern identified in the videos with the Administrator and the DON. Interview on 02/22/24 at 11:03 A.M. with the DON revealed Coach #370 advised her previously regarding Resident #43's daughter's concerns, but did not provide specifics on the concerns until 02/21/24. The DON was not aware the expressed concerns regarded a mechanical lift transfer with Resident #43 until 02/21/24. Further interview revealed the DON recalled Resident #43 was hanging from the mechanical lift, alone in her room, when she and STNA #352 returned to her room to complete the transfer to her wheelchair. Follow-up interview on 02/22/24 at approximately 11:30 A.M. with the DON revealed she did not provide any education to STNA #352 at the time she found Resident #43 alone in her room in a mechanical lift because the previous Administrator of the facility required all education and disciplinary action of STNAs to be solely through Coach #370. The DON stated she informed Coach #370 of the incident regarding STNA #352 using a mechanical lift without a second staff present. The DON further stated the current Administrator was altering that expectation and allowing the DON to educate or complete disciplinary action toward STNAs as appropriate. The facility did not have a policy or procedure regarding the use of mechanical lifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 7 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facilities bowel regime for constipation, the facility failed to ensure a resident received care and interventions for constipation. This affected one resident (#18) of two residents reviewed for bowel and bladder. The facility census was 58. Findings include: Review of Resident #18's medical record revealed an admission date of 05/22/20. Diagnoses included muscle weakness, symbolic dysfunction, constipation, dementia, major depressive disorder, anxiety disorder, insomnia, and restlessness and agitation. Review of Resident #18's Minimum Data Set (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of eight, indicating Resident #18 was moderately cognitively impaired. Resident #18 was dependent on staff for toilet use, bathing, dressing and personal hygiene. Resident #18 displayed verbal behavioral symptoms directed toward others four to six days during the review period. Review of Resident #18's care plan revised 01/24/24 revealed supports and interventions for risk for constipation. Interventions included administer medications as ordered, monitor bowel movements frequency, and monitor for complaints of abdominal pain. Resident #18's goal was to have a regular formed bowel movement at least every three days. Review of Resident #18's physician orders revealed an order dated 01/14/23 for Bisacodyl rectal suppository every 24 hours as needed for constipation. Review of the corresponding Medication Administration Record (MAR) revealed Resident #18 received no as needed suppository in the month of January 2024 or February 2024. An order dated 07/03/23 for Senna tablet 8.6 milligram two tablets every two hours as needed for constipation. Review of the corresponding Medication Administration Record (MAR) for January 2024 and February 2024 revealed Resident #18 received no as needed Senna tablets. Review of Resident #18's bowel movement tracking revealed it was documented Resident #18 did not have a bowel movement on 01/21/24, 01/22/24, 01/23/24, or 01/24/24. Review of Resident #18's progress notes revealed there was no documentation as to interventions for Resident #18's lack of bowel movement on 01/21/24, 01/22/24, 01/23/24, or 01/24/24. Interview on 02/20/24 at 4:17 P.M. with State Tested Nursing Assistant (STNA) #334 revealed Resident #18 was not always able to make her needs known. Resident #18 was confused and it depended on the day as to if Resident #18 was able to communicate what her needs were. STNA #334 reported all Resident #18's bowel movements and assistance needs were recorded in the electronic medical record. Interview on 02/21/24 at 7:07 A.M. with Licensed Practical Nurse (LPN) #366 revealed Resident #18 was confused and anxious. LPN #366 reported the bowel protocol was for any resident who went three days without a bowel movement to have an intervention completed. LPN #366 reported the aides would document when residents had bowel movements and when the residents did not. If there was three days with no bowel movement, they would start an intervention. All the residents had standing orders for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 8 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 constipation interventions and some had interventions unique to them. Level of Harm - Minimal harm or potential for actual harm Interview on 02/21/24 at 8:54 A.M. with the Director of Nursing (DON) verified it was documented Resident #18 had not had a bowel movement documented for four consecutive days 01/21/24, 01/22/24, 01/23/24, or 01/24/24. Residents Affected - Few Interview on 02/21/24 at 9:39 A.M. with the DON revealed no additional information was provided regarding interventions for Resident #18's lack of bowel movements for the four consecutive days in January where Resident #18 had no bowel movement. Review of the facility's undated bowel regime for constipation revealed residents were to receive Dulcolax Rectal Suppository 10 milligrams rectally daily if they had no bowel movement in the last three days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 9 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure clarification was received and physician orders were implemented. This affected one resident (#19) of five residents reviewed for unnecessary medications. The facility census was 58. Residents Affected - Few Findings include: Record review for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 include chronic respiratory failure, seizures, chronic kidney disease, and dementia with psychosis. Review of Resident #19's care plans dated 06/12/22 revealed a focus for impaired cognitive function related to dementia, short term memory loss and long term memory loss. Interventions include administer medications per physician order. Review of Resident #19's care plans dated 05/11/22 revealed a focus for antipsychotic medication use. Interventions include administer medications per physician order, consult with pharmacy and with physician to consider dosage reduction when clinically appropriate or at least quarterly, discuss with physician and family the need for ongoing use of medication. Review of Resident #19's prescribed medications dated 02/2024 revealed no order was in the resident's medical records for Aricept (treats memory loss and confusion) 10 milligrams (mg). Review of a physician order form for Resident #19 dated 01/23/24 revealed an order stating 'resident requested her memory pill' Aricept 10 mg. Check with house physician. Review of Resident #19's physician progress notes, nurses notes, and physician orders revealed no response or order for Aricept 10 mg. Interview on 02/22/24 at 10:00 A.M. with the Director of Nurse (DON) verified the orders for Resident #19 dated 01/23/24 came from an outside provider, the resident's psychiatrist, and were sent back with the resident to the facility with the written order form. The DON stated the nurse who received the orders did not enter the Aricept order on the form, and did not consult with the primary physician regarding the order to verify the order and frequency. The DON stated it was protocol to notify the primary physician and request clarification for all outside orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 10 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pharmacy recommended and physician approved laboratory (lab) orders were completed as recommended. This affected one resident (#5) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: Review of Resident #5's medical record revealed an admission date of 12/10/18. Diagnoses included multiple sclerosis, type II diabetes, schizoaffective disorder, major depressive disorder, and contractures of the right elbow, left elbow, right knee and left knee. Reviewed of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed Resident #5 had short and long term memory problem. Resident #5 was severely impaired with cognitive skills. Resident #5 required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of Resident #5's care plan revised 01/24/24 revealed supports and interventions for self-care deficit, risk for falls, potential for discomfort, anticoagulant use with risk for side effects, potential for drug related complications, multiple sclerosis, hospice services, risk for pain, and potential for impaired skin integrity. Review of Resident #5's pharmacy recommendations revealed on 01/24/23 the pharmacist recommended considering checking Resident #5's ammonia levels due to the last level being completed 06/28/22 and a recent decrease in responsiveness and hallucinations which led to the increase of Seroquel. The physician reviewed the recommendation and agreed. On 02/24/23 the pharmacist noted on 01/26/23 the physician agreed to check Resident #5's Ammonia level. No corresponding order was found. Please follow up. Review of Resident #5's laboratory (lab) results found no corresponding lab results for Resident #5's ammonia level. The pharmacy recommendation was not acted on and the lab for ammonia levels was not completed. Review of Resident #5's lab orders revealed his most recent order for ammonia levels was ordered 08/06/22. There was no order written in response to the 01/24/23 pharmacy recommendation. Interview on 02/22/24 at 11:03 A.M. with the Director of Nursing (DON) stated she would contact the lab and get the results if they were completed. Interview on 02/22/24 at 2:33 P.M. with the DON verified the ammonia lab was not completed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 11 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #19 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #19 included chronic respiratory failure, seizures, chronic kidney disease, and dementia with psychosis. Review of Resident #19's MDS annual assessment dated [DATE] revealed the resident had impaired cognition. No psychosis diagnosis was noted in the assessment. Per the assessment no Gradual Dose Reduction (GDR) had been attempted or had physician documentation stating a GDR was clinically contraindicated. Review of Resident #19's care plans dated 05/2022 revealed a focus for anti-psychotic medication for behavioral disturbance. Interventions included pharmacy to recommend gradual dose reduction when appropriate and at least quarterly. Review of the resident's physician prescribed medications dated from 01/2023 to 02/2024 revealed the resident was to receive Olanzapine (for depression) 2.5 mg one time in the morning and Olanzapine (for psychotic disorder) 5 mg one time at bedtime, Escitalopram (for depression) 20 mg one time a day, and Primidone 50 mg in the morning for seizures. Review of the facility's pharmacy reviews dated from 01/2023 to 01/2024 for irregularities in the medication records for Resident #19 revealed the pharmacist found irregularities in the months of 02/24/23, 04/24/23, 7/24/23, and 01/23/24. Review of the physician responses for 02/24/23 revealed the pharmacist recommended the physician to attempt a GDR for the Escitalopram 20 mg for depression. No GDR was recommended for the Olanzapine medication. On the document there was no response documented from the physician. Review of the pharmacist's recommendation dated 04/24/23 revealed a notation for the facility to obtain the psychiatry notes for reviews of the current anti-psychotic medications. Further review of the resident's medical records revealed no physician response for the 04/24/23 recommendation and no documentation for the psychiatrist in the medical records. No documentation for the pharmacist or physician was in the medical records for the 07/24/23 and 01/23/24 irregularities found. Interview on 02/21/24 at 4:00 P.M. with the DON revealed the primary physician had not responded to the pharmacy recommendations dated 02/24/23, 04/24/23, 07/24/23, and 01/23/24. Per the DON, Resident #19's anti-psychotic medications are managed by her outside psychiatrist. The DON stated there has been no attempted GDRs for any of her medications and the facility didn't have any of the outside psychiatrist's documentation or rationales for the GDR attempts. The DON verified when the pharmacist has made recommendations to attempt GDRs for Resident #19, the primary physician refers the DON to have the outside psychiatrist review the medications. The DON stated the facility has attempted to get information for the medical records from the outside psychiatrist but has been unsuccessful and has not attempted recently to receive information from the psychiatrist regarding the medications. Review of the facility policy titled, 'Gradual Dose Reduction, dated 10/2022 revealed GDRs will be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 12 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few attempted for all anti-psychotic and anti-depressant medications at least annually after the first year the resident's are prescribed the medications. Based on staff interview, record review, and review of the facility policy, the facility failed to ensure pharmacy recommendations for gradual dose reductions for psychotropic medications were addressed. This affected two (#43 and #19) of five residents reviewed for unnecessary medications. The facility census was 58. Findings include: 1. Review of the medical record for Resident #43 revealed an admission date of 07/02/22 with diagnoses of anxiety and depression. Resident #43 was under hospice care since 07/25/22. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and received antianxiety and antidepressant medications. Review of a physician order dated 07/25/22 revealed Resident #43 received lorazepam (an antianxiety medication) 0.5 milligrams (mg) one tablet by mouth every four hours as needed. Review of a physician order dated 11/11/22 revealed Resident #43 received buspirone (an antianxiety medication), 2.5 mg by mouth twice daily. Review of a documented titled, Note to Attending Physician/Prescriber, dated 05/27/23, revealed the pharmacist recommended the provider address the ongoing as-needed prescription for lorazepam for Resident #43 and for the provider to provide a length of treatment, and if more than 14 days, a rationale for ongoing use. Further review revealed no response from the provider. Review of a documented titled, Note to Attending Physician/Prescriber, dated 06/28/23, revealed the pharmacist recommended the provider address a gradual dose reduction for buspirone for Resident #43. Further review revealed no response from the provider. Interview with the Director of Nursing (DON) on 02/21/24 at approximately 3:00 P.M. revealed the facility could provide no additional evidence the provider responded to the pharmacist's recommendations on 05/27/23 or 06/28/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 13 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, staff interview, and review of the policy for medication storage, the facility failed to ensure medication carts were secured and medications were placed in the medication cart. This affected two (Residents #29 and #34) of two residents observed for medication administration. The facility census was 58. Findings include: 1. Observation of medication pass on 02/20/24 at 4:00 P.M. with Licensed Practical Nurse (LPN) #366 with Resident #29, revealed LPN #366 prepared the correct amount of Humalog into the syringe. LPN #366 placed the Humalog on top of the medication cart. LPN #366 followed Resident #29 into his room and shut the door to inject his insulin in his abdomen. LPN #366 was not in direct sight of the medication cart which was not secured and the insulin was left on top of the medication cart. Interview with LPN#366 on 02/20/24 at 4:08 P.M. verified he left the medication of Humalog on top of the unsecured medication cart and should have put back into the cart and secured the cart. 2. Observation of medication pass on 02/20/24 at 4:44 P.M. with LPN #378 with Resident #34, revealed she removed Dilaudid one half tablet and then realized she did not have any water or ice to pass for the resident. LPN #378 was observed walking away from the unsecured medication cart and went into another room to retrieve ice, which was out of sight of the unlocked medication cart. Interview with LPN #366 on 02/20/24 at 4:44 P.M. verified she walked out of sight of the unsecured medication cart while retrieving ice from another room. Review of facility policy titled, Medication Storage, dated 07/23/19 revealed medications and biologicals are stored safely, securely and properly following manufacturer's recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members authorized to administer medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 14 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility recipes, and review of the facility menus, the facility failed to follow menus as planned by not following recipes, by not using portioned serving utensils, by not offering all menu items to each resident, and by not offering the main meal before offering a nutritionally unequal alternative. This affected Resident #5 and Resident #34 and had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #40, #42, #43, #46, #47, and #59) and House 3 (#1, #16, #18, #22, #26, #27, #37, #38, #48, and #49). The facility census was 58. Findings include: 1. Review of the medical record for Resident #5 revealed an admission date of 12/10/18 with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of the current physician order dated 01/08/24 revealed Resident #5 received regular diet with pureed texture and thin liquids. 2. Review of the medical record for Resident #34 revealed an admission date of 12/23/22 with diagnoses of epilepsy, hemiplegia and hemiparesis affecting right dominant side. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 was rarely/never understood and required partial/moderate assistance for eating. Review of a physician order dated 10/25/23 revealed Resident #34 received a regular diet with mechanical soft textures and thin liquids. Review of the current care plan for Resident #34 revealed no meal preferences. Observation on 02/21/24 at 3:51 P.M. revealed State Tested Nurse Aide (STNA) #304, in House 2, preparing chicken fried rice for the evening meal. Interview with STNA #304 on 02/21/24 at 3:51 P.M. revealed she did not follow a recipe to prepare the chicken fried rice, but felt comfortable making it from her basic knowledge of cooking. Further interview and observation revealed STNA #304 used a three-pound bag of chicken tenderloins. STNA #304 stated she made three cups of rice and expected to use three eggs when assembling the meal. STNA #304 stated she was preparing enough for approximately ten residents because Resident #43 usually ate waffles, and Resident #34, on a mechanical soft diet, would receive Malt-o Meal (hot cereal) instead of the prepared meal so she would not choke. Interview on 02/21/24 at 4:19 P.M. with Dietetic Technician (DT) #337 and Registered Dietitian (RD) #379 revealed each House developed its own menu through a web-based menu program. The menu was approved weekly by RD #379 or another RD who worked at the facility once weekly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 15 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Continued interview with RD #379 confirmed the menu provided the expected portion size to provide to residents to meet their nutritional needs. RD #379 confirmed if correct portions were not used, the facility could not ensure each resident received the daily calorie and nutrient needs as estimated in the menu program. Continued interview with DT #337 stated a recipe book was available for staff, and if no recipe was available, DT #337 would provide verbal guidance on meal preparation to the staff. Observation and interview on 02/21/24 at 4:55 P.M. revealed STNA #304, in House 2, using a slotted silver spoon to serve cauliflower and a slotted spatula to serve chicken fried rice. STNA #304 confirmed the serving utensils were not intended to provide a specific portion size. STNA #304 stated she ultimately used five eggs in the chicken fried rice. Observation and interview on 02/21/24 at 5:00 P.M. with STNA #377 in House 3 revealed she made meatloaf for dinner and did not use a recipe. STNA #377 stated she used three pounds of ground beef when making the meatloaf. STNA #377 further stated there was a recipe available but she chose not to use it. Additionally, STNA #377 confirmed she used a spatula to serve the mashed potatoes and a slotted spoon to serve the mixed vegetables and neither tool was able to measure the quantity provided. Observation on 02/21/24 at 5:22 P.M. revealed STNA #377 preparing a pureed meal for Resident #5. STNA #377 pureed the meatloaf and provided a portion of mashed potatoes on Resident #5's plate. Interview at that time with STNA #377 confirmed she did not puree the mixed vegetables and did not plan to provide mixed vegetables to Resident #5 because she believed Resident #5 had plenty to eat with the meatloaf and mashed potatoes. Interview on 02/21/24 at 5:31 P.M. with STNA #304 revealed Resident #34 was on a mechanical soft diet and STNA #304 had not yet prepared or served Resident #34. Continued observation revealed STNA #304 microwaving water and preparing Malt-o Meal for Resident #34. STNA #304 stated she planned to provide a nutrition supplement with 240 kilocalories and 10 grams of protein along with the cream of wheat for the evening meal. Interview on 02/21/24 at approximately 5:40 P.M. with RD #379 confirmed the chicken fried rice and cauliflower on the menu could be prepared to an appropriate mechanical soft texture and provided to Resident #34. Observation at that time revealed a blender on the counter. Further interview with RD #379 revealed the substitution of Malt-o Meal and a nutrition supplement for the evening meal would be appropriate if it was based on Resident #34's preference. Follow-up interview on 02/21/24 at 5:44 P.M. with STNA #304 revealed STNA #304 did not offer Resident #34 the main meal because Resident #34 had impaired cognition. Review of the facility recipe for meatloaf for 12 servings revealed the portion of ground beef should be 4 and 3/4 cup and the recipe should also include one cup of ground pork. Regarding the recipe for chicken fried rice, the facility provided a statement indicating the meal should have come pre-packaged and cooked according to the directions on the bag. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 16 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure food intolerance's were honored at meals. This affected one (#5) of one resident reviewed for meal intolerance's. The facility census was 58. Findings include: Review of the medical record for Resident #5 revealed an admission date of 12/10/18 with diagnoses multiple sclerosis and type II diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5's level of cognition was not assessed. Resident #5 was on a therapeutic, mechanically altered diet and required maximal assistance with all activities of daily living. Resident #5 was on hospice at the time of the review. Review of the current physician order dated 01/08/24 revealed Resident #5 received regular diet with pureed texture and thin liquids. Review of the allergies documented in the electronic medical record for Resident #5 revealed lactose intolerance was added to his profile on 04/05/23. Review of the meal intake documentation for 02/21/24 revealed Resident #5 consumed 26-50% of the evening meal. Observation on 02/21/24 at 8:09 A.M. revealed State Tested Nurse Aide (STNA) #335 preparing breakfast for Resident #5. STNA #335 prepared oatmeal using lactose-free milk after explaining Resident #5 was lactose intolerant. Observation on 02/21/24 at 5:22 P.M. revealed STNA #377 preparing Resident #5's evening meal. STNA #377 used regular milk to thin the meatloaf she pureed and plated for Resident #5. STNA #377 also scooped a serving of mashed potatoes onto Resident #5's plate. Interview at that time with STNA #377 confirmed she prepared the mashed potatoes using regular milk and butter. STNA #377 stated Resident #5 did not have any food allergies. Interview on 02/22/24 at 9:38 A.M. with STNA #301 found a list of diet orders for residents printed 02/20/24. Review of the printout revealed nothing regarding lactose intolerance for Resident #5. Further interview with STNA #301 revealed she was unaware whether Resident #5 had any food allergies. Interview on 02/22/24 at 11:32 A.M. with the Administrator verified Resident #5's allergy list included lactose intolerance. The Administrator stated his intolerance to lactose was not a true allergy. Additionally, the Administrator confirmed Resident #5 consumed approximately 26-50% of his meal on the evening of 02/21/24. Interview on 02/22/24 at 2:31 P.M. with STNA #377 revealed she received in report from the previous shift Resident #5 had diarrhea in the morning on 02/22/24. STNA #377 stated Resident #5 did not normally have diarrhea. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 17 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of the temperature logs, and review of facility policies, the facility failed to ensure refrigerator and dishwasher temperatures were monitored and documented, failed to ensure safe food storage, and failed to sanitize thermometers between food items. This had the potential to affect all residents in House 2 (#6, #8, #20, #32, #33, #34, #40, #42, #43, #46, #47, and #59) , House 4 (#3, #9, #12, #17, #19, #21, #25, #39, #41, #52, #156, and #60), and House 5 (#2, #4, #13, #23, #35, #51, #157, #158, #159, #160, and #161). The facility identified all residents in these houses received food from the kitchen. The facility census was 58. Findings include: Interview on 02/20/24 at 8:34 A.M. with State Tested Nurse Aide (STNA) #302 revealed she did not know the process for documenting refrigerator and freezer temperatures. Interview and observation on 02/20/24 at 8:42 A.M. with STNA #317, in House 2, confirmed two containers of food labeled for Resident #59 were undated. One container contained deviled eggs with liquid around the bottom of the container. Additional observation and interview confirmed a personal food item for Resident #47 with an illegible date. Additionally, STNA #317 confirmed the strawberries in the refrigerator were moldy. Concurrent observation revealed a sign posted on the refrigerator directing staff to date all food items. Further interview with STNA #317 revealed she could not find the refrigerator thermometer. Continued observation and interview with STNA #317 confirmed there were scoops in the flour, sugar, and cereal bins. STNA #317 said the scoops were washed periodically, but remained in the containers for convenience. Interview on 02/20/24 at 9:06 A.M. with STNA #338, in House 4, revealed she was not sure how to monitor the refrigerator temperature. Interview and observation of the refrigerator and dishwasher logs on 02/20/24 at 9:08 A.M. with STNA #306 confirmed no documentation of P.M. refrigerator and freezer temperatures since 02/09/24, and no temperatures were documented for any shift on 02/18/24 and 02/19/24. Additionally, the dishwasher temperature log was blank from 02/01/24 through 02/09/24 for day shift, and no documentation was completed for night shift for the month of February 2024. Observation on 02/20/24 at 9:15 A.M. in House 5 revealed an opened gallon of milk dated 02/04/24 and a full gallon of milk dated 02/14/24 in the refrigerator. Interview on 02/20/24 at 9:16 A.M. with STNA #307 confirmed the milk was expired. Further interview revealed she did not serve any residents milk that morning. Further observation of the refrigerator and interview with STNA #307 on 02/20/24 beginning at 9:16 A.M. revealed two plastic bags of bacon were previously opened and undated and one plastic bag of sausage was previously opened and undated. Additionally, STNA #307 stated she did not know how to use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 18 of 19 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/22/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avalon by Otterbein at Perrysburg 3525 - 3533 Rivers Edge Drive Perrysburg, OH 43551 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the probe thermometer in the refrigerator to verify refrigerator temperatures. STNA #307 stated she used the temperature visible inside the refrigerator. Observation revealed the temperature she documented was a lighted read-out of the temperature setting for the refrigerator, not a thermometer. Observation and interview on 02/20/24 at 9:25 A.M. with STNA #364 confirmed the refrigerator/freezer temperature log for February 2024 was missing documentation for all entries on 02/03/24, 02/04/24, 02/17/24, and 02/18/24, and was missing P.M. temperatures for all days except 02/09/24. Interview on 02/20/24 at 9:27 A.M. with Dietetic Technician (DT) #337 stated she was involved in oversight of food safety and temperatures logs. DT #337 stated the facility was attempting to improve their documentation on temperatures. Interview on 02/21/24 at 8:09 A.M. with DT #337 revealed scoops should not be left in food bins. Observations on 02/21/24 between 4:49 P.M. and 4:55 P.M. in House 2 revealed STNA #304 taking temperatures of chicken fried rice, egg rolls, and cauliflower. STNA #304 used a digital thermometer and wiped it on a paper towel between foods. Interview on 02/21/24 at 4:54 P.M. with STNA #304 confirmed she wiped the thermometer on the same paper towel between taking the temperature of the next food. Review of the policy Refrigerator and Freezer Temperatures Policy & Procedure, revised 05/2013, revealed refrigerator and freezer temperatures should be checked twice daily and recorded on the log. Review of the policy Dishwashing, revised 04/27/21, revealed the dishwasher temperature should be recorded on the Dishwasher Monitoring Log. Review of the policy Food Handling and Preparation, revised 04/26/21, revealed clean, sanitized utensils should be used when preparing food. Review of the policy Food Storage Policy & Procedure, revised 05/2013, revealed the purpose of the policy was to assure that all food was stored, labeled, and dated properly to assure stock rotation and prevent food illness. Review of the undated document Resource for Families revealed all foods in unmarked or unlabeled containers should be marked with the current date the food item was stored. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366354 If continuation sheet Page 19 of 19